Devices and methods for cardiac annulus stabilization and treatment

ABSTRACT

Devices and methods generally provide enhanced stabilization, exposure and/or treatment of a cardiac valve annulus. Methods generally involve introducing a stabilizing member beneath one or more leaflets of a heart valve to engage the annulus at an intersection between the leaflets and the interior ventricular wall of the heart. Force is then applied to the stabilizing member to stabilize and/or expose the valve annulus. In some embodiments, the stabilizing member may include a series of hydraulically driven tethered anchors, such as hooks or clips, for engaging and cinching valve annulus tissue to decrease the diameter of a regurgitant valve. Alternatively, other treatments may be delivered by a stabilizing member, such as radiofrequency energy, drugs, bulking agents or shape memory stents. A second stabilizing member may also be introduced above the leaflets for further stabilization.

CROSS REFERENCE TO RELATED APPLICATIONS

The present application is related to, and contains subject matter incommon with, U.S. patent application Ser. No. 10/461043 (Attorney DocketNo. 16886-000310), filed on Jun. 13, 2003, which is assigned to theassignees of the present invention, and which is hereby incorporatedfully by reference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates generally to medical devices and methods.More particularly, the invention relates to devices and methods forenhancing cardiovascular valve repair, especially the repair of heartvalves such as the mitral and tricuspid valves.

In recent years, many advances have been made to reduce the invasivenessof cardiac surgery. In an attempt to avoid open, stopped-heartprocedures, which may be accompanied by high patient morbidity andmortality, many devices and methods have been developed for operating ona heart through smaller incisions, operating on a beating heart, andeven performing cardiac procedures via transvascular access. Differenttypes of cardiac procedures, such as cardiac ablation techniques fortreating atrial fibrillation, stenting procedures for atherosclerosis,and valve repair procedures for treating conditions such as mitral valveregurgitation have experienced significant technological advances. Inimplementing many minimally invasive cardiac surgery techniques,especially beating-heart techniques, one of the most significantchallenges is exposing and stabilizing a portion of cardiac tissue to beoperated upon. Another challenge, once exposure and stability areachieved, is to effectively deploy a given treatment into or on thetarget cardiac tissue using minimally invasive devices.

One type of cardiac surgery which may benefit from less invasivetechniques is heart valve repair. Traditional treatment of heart valvestenosis or regurgitation, such as mitral or tricuspid regurgitation,typically involves an open-heart surgical procedure to replace or repairthe valve. Valve repair procedures typically involve annuloplasty, a setof techniques designed to restore the valve annulus shape and strengthenthe annulus. Conventional annuloplasty surgery generally requires alarge incision into the thorax of the patient (a thoracotomy), andsometimes a median sternotomy (cutting through the middle of thesternum). These open heart, open chest procedures routinely involveplacing the patient on a cardiopulmonary bypass machine for sustainedperiods so that the patient's heart and lungs can be artificiallystopped during the procedure. Finally, valve repair and replacementprocedures are typically technically challenging and require arelatively large incision through the wall of the heart to access thevalve.

Due to the highly invasive nature of open heart valve repair orreplacement, many patients, such as elderly patients, patients havingrecently undergone other surgical procedures, patients with comorbidmedical conditions, children, late-stage heart failure patients, and thelike, are often considered too high-risk to undergo heart valve surgeryand are relegated to progressive deterioration and cardiac enlargement.Often, such patients have no feasible alternative treatments for theirheart valve conditions.

To obviate this situation, a number of devices and methods for repairingcardiac valves in a less invasive manner have been described. Somedevices provide for heart valve repair through minimally invasiveincisions or intravascularly, while others improve upon open heartsurgical procedures on beating hearts, stopped hearts or both. Forexample, several improved devices and methods for heart valve repair aredescribed in one or more patent applications filed by the inventors ofthe present invention and assigned to the assignee of the presentinvention. For further description of such devices and methods,reference may be made to U.S. patent application Ser. No. 10/461043(Attorney Docket No. 16886-000310), filed on Jun. 13, 2003, previouslyincorporated by reference.

As mentioned above, some of the difficulties in performing minimallyinvasive intracardiac surgery include exposing and stabilizing an areaof cardiac tissue to be operated upon and effectively operating on thattissue using minimally invasive instruments. Sufficient exposure isessential for allowing the physician to locate and perform a procedureon the targeted cardiac tissue. Stabilization further facilitates anintracardiac procedure, especially in a beating heart. In minimallyinvasive, beating heart surgery on a cardiac valve annulus, exposure andstabilization are especially challenging, due to rapid movement of theannulus and the heart, the small size of the annulus, and theblood-filled surgical field. While a cardiac valve may be visualized viatransesophageal echocardiogram (TEE), it is much more difficult tolocate the annulus itself, as it is basically a small band of fibroustissue. Exposure of the annulus is essential, however, since annulartissue is far stronger than surrounding valve leaflet and heart walltissue, and repair procedures performed on a valve annulus will be muchmore effective than those performed on other tissue adjacent theannulus. Even after a valve annulus is exposed and stabilized, it maystill be challenging to effectively and efficiently operate on theannulus to repair the valve, using minimally invasive devices.

Many minimally invasive or “less invasive” surgical procedures otherthan heart valve repair would also benefit from improved exposure and/orstabilization. For example, improved exposure and stabilization couldfacilitate other cardiac procedures, such as accessing the coronarysinus for placement of an implantable device or for performing aprocedure, placing pacemaker leads in one or more areas of the heart,ablation procedures such as ablation around the pulmonary veins to treatatrial fibrillation, atrial-septal defect repair procedures, and thelike. Improved stabilization and exposure could also be used to enhancenon-cardiac procedures such cinching or otherwise treating a bladder,stomach, gastroesophageal junction, vascular structure, gall bladder orthe like.

Therefore, it would be beneficial to have devices and methods forenhancing exposure and/or stabilization in transvascular, minimallyinvasive and other “less invasive” surgical procedures, such as heartvalve repair and other cardiac procedures. Ideally, for example, suchdevices and method could be used for exposing and stabilizing a cardiacvalve annulus for performing a valve repair procedure. Ideally, suchdevices and methods could be used in minimally invasive or “lessinvasive” beating heart procedures performed via a variety of accessroutes, such as transvascular or transthoracic. Also ideally, somedevices might be used for exposing a valve annulus, others might exposeand stabilize an annulus, and still others might expose, stabilize andadminister a therapy to an annulus, thus providing a physician withnumerous procedural options. At least some of these objectives will bemet by the present invention.

2. Description of the Background Art

Published U.S. Application 2002/0156526 describes a catheter-basedmethod for performing annuloplasty. Published U.S. Application2002/0042621 describes a heart valve annuloplasty system withconstrictable plication bands which are optionally attached to a linkagestrip. Published U.S. Application 2002/0087169 describes a remotecontrolled catheter system which can be used to deliver anchors and atether for performing an annuloplasty procedure. Other patentpublications of interest include WO01/26586; US2001/0005787;US2001/0014800; US2002/0013621; US2002/0029080; US2002/0035361;US2002/0042621; US2002/0095167; and US2003/0074012. U.S. patents ofinterest include U.S. Pat. Nos. 4,014,492; 4,042,979; 4,043,504;4,055,861; 4,700,250; 5,366,479; 5,450,860; 5,571,215; 5,674,279;5,709,695; 5,752,518; 5,848,969;5,860,992; 5,904,651; 5,961,539;5,972,004; 6,165,183; 6,197,017; 6,250,308; 6,260,552; 6,283,993;6,269,819; 6,312,447; 6,332,893; and 6,524,338. Publications of interestinclude De Simone et al. (1993) Am. J. Cardiol. 73:721-722, and Downinget al. (2001) Heart Surgery Forum, Abstract 7025.

BRIEF SUMMARY OF THE INVENTION

Devices and methods of the present invention are generally used tofacilitate transvascular, minimally invasive and other “less invasive”surgical procedures, by enhancing exposure, stabilization and/or thelike of a tissue or structure upon which a procedure is to be performed.“Less invasive,” for the purposes of this application, means anyprocedure that is less invasive than traditional, large-incision opensurgical procedures. Thus, a less invasive procedure may be an opensurgical procedure involving one or more relatively small incisions, atransvascular percutaneous procedure, a transvascular procedure viacut-down, a laparoscopic or other endoscopic procedure, or the like.Generally, any procedure in which a goal is to minimize or reduceinvasiveness to the patient may be considered less invasive.Furthermore, although the terms “less invasive” and “minimally invasive”may sometimes be used interchangeably in this application, neither thesenor terms used to describe a particular subset of surgical or otherprocedures should be interpreted to limit the scope of the invention.Generally, stabilization/exposure devices and methods of the inventionmay be used in performing or enhancing any suitable procedure.

As mentioned above, the present application typically describes devicesand methods for stabilization and/or exposure in the context of heartvalve repair, and more specifically mitral valve repair to treat mitralregurgitation. It should be emphasized, however, that devices andmethods of the invention may be used in any suitable procedure, bothcardiac and non-cardiac. For example, they may be used in procedures torepair any heart valve, to repair an atrial-septal defect, to access andpossibly perform a procedure from (or through) the coronary sinus, toplace one or more pacemaker leads, to perform a cardiac ablationprocedure such as ablating around pulmonary veins to treat atrialfibrillation, and/or the like. In other embodiments, the devices andmethods may be used to enhance a laparoscopic or other endoscopicprocedure on any part of the body, such as the bladder, stomach,gastroesophageal junction, vasculature, gall bladder, or the like.Therefore, although the following description typically focuses onmitral valve and other heart valve repair, such description should notbe interpreted to limit the scope of the invention as defined by theclaims.

That being said, the present invention generally provides devices andmethods for enhanced stabilization, exposure and/or treatment of acardiac valve annulus. Methods generally involve introducing astabilizing member beneath one or more leaflets of a heart valve toengage the ventricular side of the annulus at an intersection betweenthe leaflets and the interior ventricular wall of the heart. Thestabilizing member will usually be curved or C-shaped to conform to atleast a portion of the ventricular side of the annulus, and force isapplied to the stabilizing member to engage and stabilize the valveannulus. By “stabilize,” it is meant that the annulus will be at leastpartially immobilized relative to the cardiac tissue surrounding theannulus, at least partially delineated or exposed relative to cardiactissue surrounding the annulus, or both. For example, in some instances“stabilization” may not involve immobilizing annular tissue but mayinstead involve moving or positioning annular tissue in such a way toallow enhanced visualization of that tissue relative to surroundingtissues.

As just mentioned, in addition to stabilizing, methods and apparatus ofthe present invention may also help expose, position, or delineate thevalve annulus, to enhance the physician's ability to view and operate onthe annular tissue. Some embodiments also include a second stabilizingmember, to be introduced above the leaflets, allowing a physician tograsp or clamp annular tissue between the upper and lower stabilizingmembers for further stabilization. Various embodiments further providefor treatment of a valve annulus. For example, either the upper or lowerstabilizing member may include actuators or effectors for performing anyone or more of a variety of interventions. For example, either or bothstabilizing members may be adapted to deliver devices for constrictingor reshaping the valve annulus to treat regurgitation or otherconditions. The devices may comprise anchors, tethered anchors, rings,or the like for reinforcing or cinching the annulus. In a specificexample, the stabilizing member may be configured to hydraulically orotherwise deliver a series of tethered hooks, tethered clips or othertethered anchors or fasteners for engaging and cinching valve annulustissue to decrease the diameter of a regurgitant valve. Thestabilizer(s) will also be adaptable for delivering other therapies,including applying radiofrequency energy (or other heat sources) toshrink the collagen tissue in the annulus, delivering bulking agents,delivering drugs and biological agents such as growth factors,delivering agents for providing cell dedifferentiation, and/or the like.

In most cases, the methods of the present invention will be performed ona beating heart. Access to the beating heart may be accomplished by anyavailable technique, including intravascular, transthoracic, and thelike. In addition to beating heart access, the methods of the presentinvention may be used for intravascular stopped heart access as well asstopped heart open chest procedures.

In one aspect of the invention, a method for stabilizing a valve annulusof a heart for performing a procedure on the valve annulus involvesfirst introducing at least a first stabilizing member beneath one ormore leaflets of a valve of the heart to engage an intersection betweenat least one leaflet and the interior ventricular wall of the heart.Force is then applied to the first stabilizing member to stabilize thevalve annulus. Usually, the stabilizing member engages the ventricularannulus (in the case of a mitral valve), and applying force comprisesdrawing the stabilizing member upwardly against the annulus toimmobilize the annular tissue relative to the surrounding tissue. When asecond stabilizing member is employed, applying force comprises applyingopposed forces with the “upper and lower” stabilizing members to furtherstabilize the annular tissue. Such methods may be used on any of anumber of cardiac or circulatory valves or other body structures such asvalves in body lumens, but in one embodiment, for example, the firststabilizing member is passed beneath the posterior leaflet of the mitralvalve. In addition to stabilizing the annular tissue, applying pressurewith the stabilization device may also expose the valve annulus fromsurrounding tissue of the heart, for improved visualization and accessby the physician.

In some embodiments, introducing the device comprises advancing aflexible, elongate catheter through vasculature of a patient to theheart, with at least a first stabilizing member comprising ashape-changing member at a distal end of the flexible elongate catheter.The catheter may be introduced through the vasculature with theshape-changing stabilizing member in a generally straight, flexibleconfiguration. Once it is in place beneath the leaflet at theintersection between the leaflet and the interior ventricular wall, theshape of the stabilizing member is changed to conform to the annulus andusually the shape is “locked” to provide sufficient stiffness orrigidity to permit the application of force from the stabilizing memberto the annulus. Shaping and optionally locking the stabilizing membermay be accomplished in any of a number of ways, such as applying tensionto tensioning cord(s), as described in detail below.

In transthoracic and other embodiments, the stabilizing member may bepre-shaped, and the method may simply involve introducing thestabilizing member(s) under and/or over the valve leaflets. Thepre-shaped stabilizing member(s) may be rigid or formed from a shapememory material such as nitinol, spring stainless steel, or the like.

Force applied to the first stabilizing member is often upwardlydirected, though lateral forces are also possible. In addition tostabilizing with force from below the annulus, stabilizing mayoptionally include introducing a second stabilizing member over thevalve leaflets. By moving the second stabilizing member toward the firststabilizing member, a physician may grip or clamp all or a portion ofthe valve annulus.

In another aspect, a method for performing a procedure on a stabilizedvalve annulus includes advancing a flexible, elongate stabilizingcatheter through vasculature of a patient to the heart. Next, ashape-changing stabilizing member on the catheter is positioned beneathone or more leaflets of a valve of the heart to engage the lower orventricular annulus at an intersection between at least one leaflet andan interior ventricular wall of the heart. The shape of the stabilizingmember is then changed and optionally locked to conform to the annulus,and an upward and/or other force is applied to the stabilizing member tostabilize the valve annulus.

In still another aspect of the present invention, a method forconstricting a valve annulus in a beating heart comprises introducing atleast a first stabilizing member beneath one or more leaflets of a valveof the heart to engage the annulus at an intersection between at leastone leaflet and an interior ventricular wall of the heart. Force is thenapplied to the first stabilizing member to stabilize the valve annulus.A plurality of individual anchors, such as hooks, clips, barbs, T-tags,rings, anchors made of resorbable polymers such as polylactic acid orpolyglycolic acid, or the like, may then be placed at circumferentiallyspaced-apart locations about at least a portion of the valve annuluswhile the valve annulus remains stabilized. The anchors may then becinched via a tether to circumferentially tighten the annulus.Optionally, the method may further include introducing at least a secondstabilizing member over the valve leaflets and moving the secondstabilizing member toward the first stabilizing member to furtherstabilize the annulus. In some embodiments, securing the anchorscomprises driving the anchors from one of the first and secondstabilizing members. Driving the anchors, in turn, may involve inflatingan expandable balloon in one of the members to force the anchors atleast partially out of the member into tissue of the valve annulus.Optionally, securing the anchors may also involve driving the anchorsthrough tissue of the valve annulus into a anchor receiving piececoupled with the other stabilizing member.

Throughout the present application, the term “anchor” is frequently usedto a device for coupling with a valve annulus or other bodily structure.For the purposes of this application, “anchor” means any fastener orother attachment device. Thus, an anchor may be a hook, such as a curvedhook or a straight, barbed hook, a clip, a T-tag, a ring, an adhesivestrip, a shape-memory fastening device or any other fastener.Furthermore, anchors may be made of any suitable material. For example,an anchor may be made of a metal, such as stainless steel, or mayalternatively be made of a bioresorbable material such as polylactate orpolyglycolate, such that over time, after a body structure has repaired,the anchors may be resorbed. Therefore, although various examples ofanchors are described below and various terms such as “hooks” may beused to describe fastening devices of the invention, these terms shouldnot be interpreted to limit the scope of the invention as defined by theclaims.

In yet another aspect of the invention, a device for enhancing asurgical procedure on a valve annulus of a heart includes an elongatebody having a proximal end and a distal end and at least a firststabilizing member at the distal end of the shaft. Generally, the firststabilizing member is passable under one or more leaflets of a valve ofthe heart to engage an intersection between at least one leaflet and aninterior ventricular wall of the heart. In some embodiments, theelongate body comprises a rigid shaft. In alternative embodiments, theelongate body comprises a flexible catheter, so that the firststabilizing member may be passed into the heart and under the one ormore leaflets via a transvascular approach.

The first stabilizing member may comprise a shape-changing portion. By“shape-changing,” it is meant that at least a segment of the stabilizingmember may be transitioned between (a) a straight or flexibleconfiguration (to facilitate introduction) and (b) a fixed-shapeconfiguration, generally a curved or C-shaped segment which conforms tothe shape of the valve annulus. Such shape-changing may be accomplishedby a variety of mechanical approaches. In some embodiments, for example,the first stabilizing member may include a slotted, segmented orsectioned tube coupled with one or more pull cords. Tension may beapplied to one pull cord to bend the segmented tube into a C-shape,while tension may be applied to the other cord to bend the tube up, orproximally. Generally, a segmented tube and two pull cords can be usedto shape a stabilizing member around two bends having any desiredconfiguration. In another embodiment, a shape-memory material may beincluded in the first stabilizing member, and introducing fluid into themember may cause it to change from a straight configuration to aC-shape. In some embodiments, the shape-changing portion may be lockedin position to enhance stabilization of the annulus.

In some embodiments, the first stabilizing member includes asemicircular housing, a plurality of tethered anchors disposed withinthe housing, and at least one expandable balloon for driving theplurality of anchors into tissue of the valve annulus. In someembodiments, the device may include an inflation actuator for inflatingthe expandable balloon, a release actuator for releasing the anchorsfrom the housing, and a cinching actuator for cinching a tether coupledwith the tethered anchors to reduce a diameter of the valve annulus. Thefirst stabilizing member may be configured to allowing driving of theplurality of anchors in any suitable direction or configuration. Forexample, in some embodiments the first stabilizing member will beconfigured for positioning under a heart valve annulus and for drivinganchors upwards (or superiorly) into or through the annulus. In anotherembodiment, a stabilizing member may be configured for positioning abovean annulus and for driving anchors downwards. Alternatively, astabilizing member may be positioned outside a heart wall or otherstructure, with anchors driven inwardly. And as discussed above, thesedevices may be used to perform other cardiac and non-cardiac procedures,such as anchoring and cinching a gastroesophageal junction, bladderoutlet or other structure.

As mentioned above, some embodiments also include at least a secondstabilizing member movably coupled with the elongate shaft, wherein thesecond stabilizing member may be moved toward the first stabilizingmember to grip and stabilize the valve annulus. Optionally, suchembodiments may also include one or more anchor receiving pieces coupledwith the second stabilizing member for receiving distal ends of theplurality of anchors driven through the tissue of the valve annulus. Insome embodiments, each of the first and second stabilizing memberscomprises a flexible rigidifying portion. Alternatively, each of thefirst and second stabilizing members may comprise a rigid member. Someembodiments may also include a handle near the proximal end of the shaftfor moving the second stabilizing member toward the first stabilizingmember to grip the valve annulus.

In alternative embodiments, either the first stabilizing member, thesecond stabilizing member or both may include any of a number of annulustreatment devices. For example, in one embodiment a stabilizing membermay include an energy deliver device, such as a radiofrequency deliverydevice, for transmitting energy to a valve annulus to constrict theannular tissue. In another embodiment, a stabilizing member may includea mechanical support member or other deployable device that is couplablewith a valve annulus. For example, a shape memory stent may be coupledwith a stabilizing member such that when the stent is coupled withannular tissue and deployed, it shrinks longitudinally to reduce thediameter of the annulus. In other embodiments, multiple such stents maybe used. These and other embodiments are described more fully below withreference to the drawing figures.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a cross-sectional view of a heart with a flexiblestabilization device being positioned for stabilizing a valve annulus,according to one embodiment of the present invention;

FIGS. 1A and 1B are cross-sectional views of a valve leaflet, valveannulus, atrial wall and ventricular wall, with a stabilization devicein place for stabilizing and exposing the annulus, according to oneembodiment of the present invention;

FIG. 2 is a perspective view of a stabilization device having twostabilization members, according to one embodiment of the presentinvention;

FIG. 3 is a cross-sectional view of a valve leaflet, valve annulus,atrial wall and ventricular wall, with a stabilization device in placehaving upper and lower stabilization members, according to oneembodiment of the present invention;

FIG. 4 shows a stabilization device as in FIG. 3 with a tethered clipplaced in the valve annulus, according to one embodiment of the presentinvention;

FIG. 5 shows a stabilization device having a balloon-driven clip applieras its upper stabilizing member, according to one embodiment of thepresent invention;

FIGS. 5A and 5B show a stabilization device having a balloon-driven hookapplier as its upper stabilizing member, and a method for using same,according to one embodiment of the present invention;

FIGS. 5C and 5D show a stabilization device having a balloon-driven hookapplier as its upper stabilizing member, a lower stabilizing membercarrying a hook receiver, and a method for using same, according to oneembodiment of the present invention;

FIG. 6 is a perspective view of a balloon-driven hook applier forapplying hooks to a cardiac valve annulus, according to one embodimentof the present invention;

FIG. 7 is a close-up view of the device in FIG. 6; and

FIG. 8 is a perspective view of a balloon-driven hook applier as inFIGS. 6 and 7, with the balloon expanded and the hooks deployed,according to one embodiment of the present invention.

DETAILED DESCRIPTION OF THE INVENTION

Devices and methods of the present invention are generally used tofacilitate transvascular, minimally invasive and other “less invasive”surgical procedures, by enhancing exposure, stabilization and/or thelike of a tissue or structure upon which a procedure is to be performed.As discussed more fully above, “less invasive,” for the purposes of thisapplication, means any procedure that is less invasive than traditional,large-incision open surgical procedures. Thus, a less invasive proceduremay be an open surgical procedure involving one or more relatively smallincisions, a transvascular percutaneous procedure, a transvascularprocedure via cut-down, a laparoscopic or other endoscopic procedure, orany procedure in which a goal is to minimize or reduce invasiveness tothe patient may be considered less invasive.

The present application typically describes devices and methods forstabilization and/or exposure in the context of heart valve repair, andmore specifically mitral valve repair to treat mitral regurgitation.Devices and methods of the invention may be used in any suitableprocedure, however, both cardiac and non-cardiac. For example, they maybe used in procedures to repair any heart valve, to repair anatrial-septal defect, to access and possibly perform a procedure from(or through) the coronary sinus, to place one or more pacemaker leads,to perform a cardiac ablation procedure such as ablating aroundpulmonary veins to treat atrial fibrillation, and/or the like. In otherembodiments, the devices and methods may be used to enhance alaparoscopic or other endoscopic procedure on any part of the body, suchas the bladder, stomach, gastroesophageal junction, vasculature, gallbladder, or the like. In some embodiments, for example, devices andmethods include coupling multiple tethered anchors to a valve annulusand cinching the annulus to reduce a diameter of the valve. Similardevices and methods may be used, alternatively, to close or reduce thediameter of an atrial-septal defect, a gastroesophageal junction, or anyother suitable body lumen, valve or other structure. Therefore, althoughthe following description typically focuses on mitral valve and otherheart valve repair, such description should not be interpreted to limitthe scope of the invention as defined by the claims.

Devices and methods of the invention generally provide for enhancedstabilization, exposure and/or treatment of a cardiac valve annulus. By“stabilize,” it is meant that the annulus will be at least partiallyimmobilized relative to the cardiac tissue surrounding the annulus, atleast partially delineated or exposed relative to cardiac tissuesurrounding the annulus, or both. For example, in some instances“stabilization” may not involve immobilizing annular tissue but mayinstead involve moving or positioning annular tissue in such a way toallow enhanced visualization of that tissue relative to surroundingtissues. Methods generally involve introducing a stabilizing memberbeneath one or more leaflets of a heart valve to engage the ventricularside of the annulus at an intersection between the leaflets and theinterior ventricular wall of the heart. The stabilizing member willusually be curved or C-shaped to conform to at least a portion of theventricular side of the annulus, and force is applied to the stabilizingmember to engage and stabilize the valve annulus.

In addition to stabilizing, methods and apparatus of the presentinvention may also help expose, position, or delineate the valveannulus, to enhance the physician's ability to view and operate on theannular tissue. Some embodiments also include a second stabilizingmember, to be introduced above the leaflets, allowing a physician tograsp or clamp annular tissue between the upper and lower stabilizingmembers for further stabilization. Various embodiments further providefor treatment of a valve annulus. For example, either the upper or lowerstabilizing member may include actuators or effectors for performing anyone or more of a variety of interventions. For example, either or bothstabilizing members hay be adapted to deliver devices for constrictingor reshaping the valve annulus to treat regurgitation or otherconditions. The devices may comprise anchors, tethered anchors, rings,or the like for reinforcing or cinching the annulus. In a specificexample, the stabilizing member may be configured to hydraulically orotherwise deliver a series of tethered hooks, tethered clips or othertethered anchors or fasteners for engaging and cinching valve annulustissue to decrease the diameter of a regurgitant valve. Thestabilizer(s) will also be adaptable for delivering other therapies,including applying radiofrequency energy (or other heat sources) toshrink the collagen tissue in the annulus, delivering bulking agents,delivering drugs and biological agents such as growth factors.

In most cases, the methods of the present invention will be performed ona beating heart. Access to the beating heart may be accomplished by anyavailable technique, including intravascular, transthoracic, and thelike. In addition to beating heart access, the methods of the presentinvention may be used for intravascular stopped heart access as well asstopped heart open chest procedures.

Referring now to FIG. 1, a heart H is shown in cross section, with astabilization device 100 introduced within the heart H. Generally,stabilization device 100 comprises an elongate body with at least afirst stabilizing member 102 at its distal end for providingstabilization and/or exposure of a heart valve annulus. In someembodiments, the elongate body comprises a rigid shaft, while in otherembodiments it comprises a flexible catheter, so that the firststabilizing member may be positioned in the heart H and under one ormore valve leaflets to engage an valve annulus via a transvascularapproach. Transvascular access may be gained, for example, through theinternal jugular vein (not shown) to the superior vena cava SVC to theright atrium RA, across the interatrial septum to the left atrium LA,and then under one or more mitral valve leaflets MVL to a positionwithin the left ventricle (LV) under the valve annulus (not shown).Alternatively, access to the heart may be achieved via the femoral veinand the inferior vena cave In other embodiments, access may be gainedvia the coronary sinus (not shown) and through the atrial wall into theleft atrium.

In other embodiments, access to the heart H may be transthoracic, withthe stabilization device being introduced into the heart via an incisionor port on the heart wall. Even open heart surgical procedures maybenefit from methods and devices of the invention. Furthermore, someembodiments may be used to enhance procedures on the tricuspid valveannulus, adjacent the tricuspid valve leaflets TVL, or any other cardiacor vascular valve. Therefore, although the following descriptiontypically focuses on minimally invasive or less invasive mitral valverepair for treating mitral regurgitation, the invention is in no waylimited to that use.

With reference to FIGS. 1A and 1B, a method for using stabilizationdevice 100 is depicted in a cross-sectional view. First, as in FIG. 1A,stabilizing member 102 is positioned in a desired location under a valveleaflet L and adjacent a ventricular wall VW. The valve annulusgenerally comprises an area of heart wall tissue at the junction of theventricular wall VW and the atrial wall AW that is relatively fibrousand, thus, significantly stronger that leaflet tissue and other heartwall tissue. Stabilizing member 102 may be advanced into position underthe valve annulus by any suitable technique, some of which are describedbelow in further detail. For example, using a stabilization devicehaving a flexible elongate body as shown in FIG. 1, stabilizing member102 may be passed from the right atrium RA through the interatrialseptum in the area of the foramen ovale (not shown—behind the aorta A),into the left atrium LA. Oftentimes, stabilizing member 102 will thennaturally travel, upon further advancement, under the posterior valveleaflet to a position under the valve annulus VA, as shown in FIG. 1A.

In some embodiments, stabilizing member 102 includes a shape-changingportion which enables stabilizing member 102 to conform to the shape ofthe valve annulus VA. The catheter may be introduced through thevasculature with the shape-changing stabilizing member in a generallystraight, flexible configuration. Once it is in place beneath theleaflet at the intersection between the leaflet and the interiorventricular wall, the shape of stabilizing member 102 is changed toconform to the annulus and usually the shape is “locked” to providesufficient stiffness or rigidity to permit the application of force fromstabilizing member 102 to the annulus. Shaping and optionally lockingstabilizing member 102 may be accomplished in any of a number of ways.For example, in some embodiments, a shape-changing portion may besectioned, notched, slotted or segmented and one of more tensioningcords, wires or other tensioning devices coupled with the shape-changingportion may be used to shape and rigidify stabilizing member 102. Asegmented stabilizing member, for example, may include multiple segmentscoupled with two tensioning cords, each cord providing a differentdirection of articulation to the stabilizing member. A first bend may becreated by tensioning a first cord to give the stabilizing member aC-shape or similar shape to conform to the valve annulus, while a secondbend may be created by tensioning a second cord to articulate theC-shaped member upwards against the annulus. In various embodiments, anyconfigurations and combinations may be used to give stabilizing member102 a desired shape.

In transthoracic and other embodiments, stabilizing member 102 may bepre-shaped, and the method may simply involve introducing stabilizingmember 102 under the valve leaflets. The pre-shaped stabilizing member102 may be rigid or formed from a shape memory material such as nitinol,spring stainless steel, or the like.

Once stabilizing member 102 is positioned under the annulus, force maybe applied to stabilize the valve annulus VA, as shown in FIG. 1B. Suchforce may be directed in any suitable direction to expose, positionand/or stabilize the annulus. For example, upward and lateral force isshown in FIG. 1B by the solid-headed arrow drawn from the center ofstabilizing member 102. In other cases, only upward, only lateral, orany other suitable force(s) may be applied. With application of force tostabilizing member 102, the valve annulus VA is caused to rise orproject outwardly, thus exposing the annulus for easier viewing andaccess. The applied force may also stabilize the valve annulus VA, alsofacilitating surgical procedures and visualization.

With reference now to FIG. 2, one embodiment of a stabilization device200 may include an upper or atrial stabilizing member 202, coupled withan outer shaft 210, and a lower or ventricular stabilizing member 204coupled with an inner shaft 212. Upper stabilizing member 202 and lowerstabilizing member 204 are typically adapted for placement above andbelow a valve annulus, such as the mitral valve annulus. Stabilizingmembers 202 and 204 will typically be formed from an elastic materialhaving a geometry selected to engage and optionally shape or constrictthe valve annulus. For example, the rings may be formed from shapememory alloy, such as nitinol, from a spring stainless steel, or thelike. In other instances, however, the stabilizing members could beformed from an inflatable or other structure can be selectivelyrigidified in situ, such as a gooseneck or lockable element shaft, anyof the rigidifying structures described above, or any other rigidifyingstructure.

As described above, the device 200 may be introduced to the left atriumof a beating heart, either transeptally or through an incision in theheart wall. Once in the atrium, the lower or ventricular stabilizingmember will be introduced through the mitral valve opening, with acorner 206 of the stabilizing member typically being engaged against acommisure. The ventricular stabilizing member 204 may be adjusted sothat it lies at a junction between the valve leaflet L and theventricular wall VW, as illustrated in FIG. 3. The upper or atrialstabilizing member 202 may then be clamped down onto the upper surfaceof the annulus VA, typically by sliding outer shaft 210 down over innershaft 212. Thus, the annulus will be circumferentially clamped betweenthe stabilizing members, again as observed in FIG.3. Such clamping willstabilize the annulus relative to the remainder of the beating heart,thus facilitating subsequent minimally invasive surgical procedures. Forexample, and with reference now to FIG. 4, a clip applier may be used tointroduce individual tethered clips 156 into the valve annulus VA.Exemplary clip appliers for applying tethered clips to a valve annulusare described more fully in U.S. patent application Ser. No. 10/461043,which was previously incorporated by reference. Alternatively, atrialstabilizing member 202 could be replaced with a circular clip applier220, as shown in FIG. 5. A stabilizing device employing such a clipapplier could be used to simultaneously stabilize the annulus anddeliver clips 222 using a clip driver, such as a balloon 224.

Although not illustrated, in some instances it may be desirable toprovide a third stabilizing element on the exterior of the heart,optionally between the coronary sinus CS and circumflex artery CF orwithin the coronary sinus.

As is described further below, any stabilizing member, including anatrial stabilizing member, a ventricular stabilizing member, or both,may include one or more devices for treating a valve annulus. Suchdevices may include any suitable device for treating an annulus, and thepresent invention is not limited to any specific embodiments. Forexample, in some embodiments a stabilizing member comprises a housingfor containing a plurality of tethered anchors and a system fordelivering the anchors into annular tissue. “Anchors” may comprisecurved hooks, straight hooks, barbed hooks, clips of any kind, T-tags,shape memory hooks, or any other suitable fastener(s). Delivery ofanchors may be accomplished by any suitable device and technique, suchas by hydraulic balloon delivery as discussed below. Alternatively, anyother suitable treatment may be delivered to an annulus. For example,energy such as radiofrequency energy may be delivered to the annulus viaa stabilizing member to constrict the annular tissue. Alternatively, ashape memory stent may be delivered to the annulus such that whendeployed the stent longitudinally shrinks to constrict the annulus. Inother embodiments, one or more drugs or bulking agents may beadministered to the annulus. Therefore, although the followingdescription focuses on delivery of a plurality of tethered hooks to avalve annulus, many other types of anchors and other treatmentmodalities may alternatively be delivered using devices and methods ofthe invention.

That being said, and referring now to FIGS. 5A and 5B, in oneembodiment, upper stabilizing member 202 could be replaced with acircular hook applier 230, including a housing for multiple tetheredhooks 232 and a hook driver such as a balloon 234. Again, hooks 232 maybe replaced by any other anchors in various embodiments. Hooks 232 maybe coupled to the device via a pivot mandrel 236, so that when balloon234 is inflated, as in FIG. 5B, hooks 232 pivot around mandrel 236 toenter tissue of the valve annulus VA. Hydraulically driving curved hooks232 in this way closely replicates the motion of a surgeon manuallydriving a suture needle into tissue and allows hooks 232 to be drivenstrongly into the tissue of the valve annulus VA. After hooks 232 areengaged with the valve annulus VA, they may be cinched, using the tether(not shown), to decrease the diameter of the annulus and thus the valve.The housing, the balloon 234 and the pivot mandrel 236 may be withdrawnbefore or after cinching.

As mentioned above, in various embodiments other anchor deliverymechanisms may be used, although one or more expandable balloons areused in one embodiment. For example, other hydraulic delivery systemsmay be used, anchors may be advanced into tissue using a pull-cord, orthe like. In some embodiments, treatment devices and delivery mechanismsmay be incorporated into lower/ventricular stabilizing member 204,rather than upper/atrial stabilizing member 202. In still otherembodiments, some of which are described immediately below, bothstabilizing members 202 and 204 may include devices for treatment of thevalve annulus VA.

Additionally, and with reference now to FIGS. 5C and 5D, someembodiments may include one or more fasteners and fastener receivingpieces. For example, a circular hook applier 240, including multipletethered hooks 242 on a pivot mandrel 246 and a balloon 244 may bedisposed on the upper, atrial side of the valve annulus VA, and lowerstabilizing member 204 may carry one or more receiving pieces 248 forreceiving part of one or more of hooks 242. As shown in FIG. 5D, whenballoon 244 is inflated, it drives hooks 242 in a curved path throughtissue of the valve annulus VA and into receiving piece 248. Receivingpiece 248 may comprise any suitable material with any configuration forreceiving and holding a portion of hooks 242. In some embodiments, forexample, receiving piece 248 may comprise a Dacron strip, while in otherembodiments the fastener and fastener receiving piece may be configuredsimilar to a plastic garbage bag tie or the like. Any configuration iscontemplated within the scope of the invention. In alternativeembodiments, anchors may be driven from lower stabilizing member 204into a receiving piece carried by upper stabilizing member 202.

Referring now to FIGS. 6, 7 and 8, one embodiment of a stabilizing andhook delivery device 260 is shown. Typically, hook delivery device 260will include an elongate housing or shaft 261, which will house a seriesof hooks 264 coupled to housing 261 via a pivot mandrel 266 and coupledto one another via a tether 268. Housing 262 will also include one ormore expandable balloons 262 for driving hooks 264. Housing 262 may beflexible or rigid in various embodiments. Of course, any number, sizeand shape of hooks 264 (or other anchors) may be included in housing261. Tether 268 may be one long piece of material or two or more piecesand may comprise any suitable material, such as suture, suture-likematerial, a Dacron strip or the like. Pivot mandrel 268 may also haveany suitable configuration and be made of any suitable material. In oneembodiment, mandrel 268 is made of a metal such as stainless steel,titanium or nitinol. Expandable balloon 262 may have any suitable sizeand configuration. In some embodiments, more than one balloon may beused. As shown in FIG. 8, inflating balloon 262 drives hooks 264 in acurvilinear path (arrows) into adjacent tissue (not shown). Hooks thusdriven into tissue of a cardiac valve annulus may then be cinched, viatether 268, to reduce the valve diameter, thus treating or amelioratingvalve regurgitation.

Although the foregoing is a complete and accurate description of thepresent invention, the description provided above is for exemplarypurposes only, and variations may be made to the embodiments describedwithout departing from the scope of the invention. Thus, the abovedescription should not be construed to limit the scope of the inventionas described in the appended claims.

1-57. (canceled)
 58. A method for stabilizing a valve annulus of a heartfor performing a procedure on the valve annulus, the method comprising:introducing at least a first stabilizing member beneath one or moreleaflets of a valve of the heart to engage the annulus at anintersection between at least one leaflet and an interior ventricularwall of the heart; and applying force to the first stabilizing member tostabilize the valve annulus.
 59. A method as in claim 58, whereinintroducing comprises passing the member beneath at least the posteriorleaflet of the mitral valve of the heart.
 60. A method as in claim 58,wherein applying force to the first stabilizing member exposes the valveannulus from surrounding tissue of the heart.
 61. A method as in claim58, wherein introducing comprises advancing an elongate cathetercarrying the first stabilizing member through vasculature of a patientto the heart, wherein the first stabilizing member is adapted to changebetween a flexible configuration for introduction through thevasculature and a curved configuration to conform to the annulus.
 62. Amethod as in claim 61, further comprising changing the shape of thefirst stabilizing member to conform to the annulus.
 63. A method as inclaim 62, wherein changing the shape of the first stabilizing membercomprises articulating the stabilizing member in at least twodirections.
 64. A method as in claim 62, wherein changing the shape ofthe first stabilizing member comprises applying tension to at least afirst tensioning cord to cause a first bend in the stabilizing member.65. A method as in claim 64, wherein changing the shape furthercomprises applying tension to at least a second tensioning cord to causea second bend in the stabilizing member.
 66. A method as in claim 65,wherein the first bend comprises approximately a C-shaped bend toconform the stabilizing member to the annulus, and the second bendcomprises an upwardly directed bend.
 67. A method as in claim 62,wherein changing the shape of the first stabilizing member comprisesintroducing a fluid into a shape-memory stabilizing member.
 68. A methodas in claim 62, further comprising locking the shape of the firststabilizing member.
 69. A method as in claim 58, wherein applying forceto the first stabilizing member comprises applying upwardly directedforce in a direction from the ventricles toward the atria of the heart.70. A method as in claim 58, wherein stabilizing further comprisesintroducing at least a second stabilizing member over the valveleaflets.
 71. A method as in claim 70, further comprising moving thesecond stabilizing member toward the first stabilizing member to furtherstabilize the valve annulus.
 72. A method for stabilizing a valveannulus of a heart for performing a procedure on the valve annulus, themethod comprising: advancing a flexible, elongate stabilizing catheterthrough vasculature of a patient to the heart; introducing at least afirst stabilizing member of the stabilizing catheter beneath one or moreleaflets of a valve of the heart to engage the annulus at anintersection between at least one leaflet and an interior ventricularwall of the heart; changing the shape of the stabilizing member toconform to the annulus; and applying force to the stabilizing member tostabilize the valve annulus.
 73. A method as in claim 72, whereinchanging the shape of the first stabilizing member comprisesarticulating the stabilizing member in at least two directions.
 74. Amethod as in claim 72, wherein changing the shape of the firststabilizing member comprises applying tension to at least a firsttensioning cord to cause a first bend in the stabilizing member.
 75. Amethod as in claim 74, wherein changing the shape further comprisesapplying tension to at least a second tensioning cord to cause a secondbend in the stabilizing member.
 76. A method as in claim 75, wherein thefirst bend comprises approximately a C-shaped bend to conform thestabilizing member to the annulus, and the second bend comprises anupwardly directed bend.
 77. A method as in claim 72, wherein changingthe shape of the first stabilizing member comprises introducing a fluidinto a shape-memory stabilizing member.
 78. A method as in claim 72,further comprising locking the shape of the first stabilizing member.79. A method as in claim 72, wherein applying force to the firststabilizing member comprises applying upwardly directed force in adirection from the ventricles toward the atria of the heart.
 80. Amethod as in claim 72, wherein stabilizing further comprises introducingat least a second stabilizing member over the valve leaflets.
 81. Amethod as in claim 80, further comprising moving the second stabilizingmember toward the first stabilizing member to further stabilize thevalve annulus.
 82. A method for constricting a valve annulus in abeating heart, the method comprising: introducing at least a firststabilizing member beneath one or more leaflets of a valve of the heartto engage the annulus at an intersection between at least one leafletand an interior ventricular wall of the heart of the heart; applyingforce to the first stabilizing member to stabilize the valve annulus;and constricting at least a portion of the valve annulus while the valveannulus remains stabilized.
 83. A method as in claim 82, furthercomprising: introducing at least a second stabilizing member over thevalve leaflets; and moving the second stabilizing member toward thefirst stabilizing member further stabilize the annulus.
 84. A method asin claim 83, wherein constricting comprises attaching a mechanicalsupport structure to at least a portion of the valve annulus.
 85. Amethod as in claim 84, wherein the mechanical support structurecomprises a ring or a system of anchors and tethers.
 86. A method as inclaim 83, wherein constricting comprises applying energy to shrink atleast a portion of the annular tissue.
 87. A method for constricting avalve annulus in a beating heart, the method comprising: introducing atleast a first stabilizing member beneath one or more leaflets of a valveof the heart to engage the annulus at an intersection between at leastone leaflet and an interior ventricular wall of the heart of the heart;applying force to the first stabilizing member to stabilize the valveannulus; securing individual anchors at circumferentially spaced-apartlocations about at least a portion of the valve annulus while the valveannulus remains stabilized; and cinching a tether through the anchors tocircumferentially constrict the annulus.
 88. A method as in claim 87,further comprising: introducing at least a second stabilizing memberover the valve leaflets; and moving the second stabilizing ring towardthe first stabilizing ring to further stabilize the annulus.
 89. Amethod as in claim 88, wherein securing the anchors comprises drivingthe anchors from one of the first and second stabilizing members.
 90. Amethod as in claim 89, wherein driving the anchors from one of the firstand second members comprises inflating an expandable balloon in one ofthe members to force the anchors at least partially out of the memberinto tissue of the valve annulus.
 91. A method as in claim 89, whereinsecuring the anchors further comprises driving the anchors throughtissue of the valve annulus into an anchor receiving piece coupled withthe other of the first and second stabilizing members.
 92. A method forconstricting a heart valve annulus comprising: accessing a heart valveannulus from beneath one or more leaflets of a heart valve; introducinga tethered clip assembly to the heart valve annulus, wherein thetethered clip assembly comprises a plurality of individual clips coupledto a tether; securing the individual clips of the tethered clip assemblyat circumferentially spaced apart locations about at least a portion ofthe heart valve annulus; and cinching the tether to reduce thecircumference of at least a portion of the heart valve annulus.
 93. Themethod of claim 92 wherein the heart valve annulus is a mitral valveannulus.
 94. The method of claim 92 performed on a beating heart.